RootCauseAnalysis NRSG378

CasestudiesforAssessmentTask2NRSG3782025SemesterOne

NRSG378AssessmentTaskTwo:RootCauseAnalysis-CaseStudyABackground

At approximately 4:45 pm on a weekday, Ms. A, a registered nurse (RN) heard unusual noises from a residents room at a residential aged care facility. Initially, the RN (Ms. A) dismissedthenoises,astheresidentoftenmadenoisesinherbedroom.RN(Ms.A)grew concernedafterthenoisespersisted.RN(MsA).andacolleague,RN(Mr.B),checkedon the resident, Ms. D.

They found Ms. D lying on her side on the floor, between her bed and a chest of drawers. Shestatedshehadtrippedoverabasketforstoringpersonalitems.Theroomwasnotedto be cluttered despite regular assistance from staff with tidying. Multiple items were found on the floor, many of which may have contributed to the fall.

ImmediateResponse

When asked if she was injured, Ms D reported she could not get up and requested an ambulance. Despite her request, RN (Ms A) and RN (Mr B) decided against calling emergency services. Historically, prior incidents where ambulances were called for Mrs Ddid not uncover significant health concerns. The RNs assisted her into a recliner chair, duringwhichshemoanedbutappearedcomfortableonceseated.Anicepackwasappliedto her lower back, and the RN nurse initiated paracetamol for pain. The RN decided not to notify the on-call GP. Neither the RNs nor PCAs re-assessed Ms D until dinner because the shift was busy with other residents' call bells and medication administration rounds.

Later, Ms. D joined other residents briefly at dinner and appeared to return to her normal activities, including knitting. After dinner and overnight, Ms. D was only observed (sighted) every4hours,andsheappearedtobecomfortable.OvernightprogressnotesstatedMs.D refusedhermedicationsandvitalsignsassessment.Theprogressnotesalsoindicatedthis was unusual behaviour for Ms. D.

TheFollowingMorning

At8:00am,theincomingRN(Mr.E)foundMs.Ddifficulttorouse.Sheappearedpaleand cold to the touch, with visible injuries, including torn skin on her toes and shins with minor bleeding. Ms. D reported a second fall during the night, resulting in severe pain.RN (Mr. E) completed a set of vital signs (BP 73/35 mmHg, HR 125bpm irregular, Temp 35.7C, RR 28bpm, shallow, Oxygen saturations 92% on room air). Despite being able to respond verbally to questions, RN (Mr. E) documented in progress notes that the patient appeared abnormally confused. An ambulance was called.

MsDwastransferredtoahospitalwherediagnosticimagingrevealedunstablecervical(C1- 2) spinal injuries requiring urgent care. Despite surgical interventions, her condition resulted in quadriplegia. She was transitioned to palliative care and passed away two days later.

PossibleRootcauses

• No process for providing and escalating care for unwitnessed falls
• Inadequate response through assessment to an acute deterioration
• Inadequate staffing based on the workload and acuity of the residential aged care facility

NRSG378AssessmentTaskTwo:RootCauseAnalysis-CaseStudyBBackground

Ms. R, a 58-year-old patient, was admitted to the hospital for the acute management of a deep vein thrombosis (DVT). Her past medical history includes Type 2 diabetes mellitus, hypertension,andchronickidneydisease(stage3),herweightwas80kg.Uponadmission, Ms. R was prescribed:

• Enoxaparin80mgsubcutaneouslytwicedaily(TreatmentforDVT)
• Metformin500mgtwicedaily
• Amlodipine5mgoncedaily
• Paracetamol1gevery6hoursasneededforpain

IncidentTimeline

1. Day1:NurseAadministeredR'sscheduledmedicationsasorderedduringthe evening medication round (2000hrs).
2. Day2,morningshift:WhenNurseBwenttoadministerEnoxaparintoR,she noted a moderate sized bruise in her abdomen. She attributed this to the previous Enoxaparin injection. Ms R also complained about having new mild abdominal tenderness and feeling more fatigued. As the symptoms were mild, Nurse B administered PRN paracetamol and encouraged Ms. R to take more rest in the morning. Nurse B did not report the new changes to the medical team at the time.
3. Day2,at1300:R'sabdominalpainworsened.Herbloodpressurewasrecorded as 92/60 mmHg, heart rate was 110bpm regular and respiratory rate was 28bpm, shallow. Nurse B paged a junior medical officer (JMO) who responded after an hour and ordered a routine blood profile (see below), chest x-ray and frequent vital sign monitoring. Nurse B discussed this plan during handover with Nurse C, who was commencing the afternoon shift.
4. Day2,evening:Thebloodpanelresultsareasfollows:

The JMO called the ward after reviewing the bloods. Nurse C was on break, so Nurse D took the call. The JMO verbally requested to cease the enoxaparin. When Nurse C returned from break, she was unaware of the verbal order and administered

another80mgdoseofEnoxaparin.

5. Day 3, Early Morning:R became hypotensive (BP 78/54 mmHg), tachycardic (HR 131bpm, regular) and reported worsening headache and abdominal pain. A CT scan revealed a significant retroperitoneal bleed. She was transferred to the intensive care unit (ICU) for urgent resuscitation and intervention.
6. Outcome:R required emergency surgery to control the bleed and spent two weeks in the ICU. Although she survived, she experienced a prolonged recovery, including significant deconditioning and new-onset anxiety related to her hospital stay.

Possible Root causes

• Inadequate processesforurgentlyceasingmedications(phoneorders)
• Inadequate processesformedicationreviewpendingrelatedpathologyresults
• Inadequate recognitionandresponsetosignsofacutedeterioration(bleeding)